One Night in an E.R.

By Peter Tyson

Posted 03.27.01

NOVA

What is life in an emergency room really like? How, for instance, does it stack up against the popular TV show "E.R.," which is likely most people's only view of how such a place runs? One snowy Friday night, two attending E.R. doctors at Massachusetts General Hospital in Boston graciously allowed me to shadow them for eight and a half hours as they made their rounds. These doctors, along with their residents and many of their patients, were generously forthcoming, offering a fascinating peek into a big-city E.R. and the lives that intersect there. Just one thing, I was told: Don't call it the E.R. At Mass General, it's the E.D.—Emergency Department.

HOUR ONE
6:15 p.m.

I check my watch and record the time, as I plan to do throughout what should be an interesting night. I'm supposed to be at Mass General at 6, but I'm currently stuck on Storrow Drive along the Charles River. Due to the snowstorm, traffic is at a near dead stop. An ambulance with siren blaring threads its way down the middle between the two lanes. It's probably going right where I'm going. For a moment, I consider sneaking in behind it and throwing on my flashers but think better of it.

6:28 p.m.

After getting off the drive and sneaking through downtown Boston, I finally arrive at Mass General. I meet Nicole Gustin, from the Public Affairs office, who will accompany me this evening.

6:42 p.m.

I'm introduced to Dr. Michelle Finkel, the attending physician in the Acute/Trauma section of the hospital's E.D. Pert and confident, Finkel has short brown hair and a wide smile. She graduated from Stanford and Harvard Medical School, and she finished her residency here last June. At 31, she is the youngest attending physician in the E.D. It's immediately clear she accepts my presence and does not see me as an annoyance.

6:50 p.m.

Finkel leads me on a quick tour of the E.D., beginning with the 16-bed Major Multipurpose, or MAMP, where less severe and chronic cases are taken, then into the four-bed Pediatric unit. Finally we head into the 10-bed Acute/Trauma section, where patients with gastrointestinal bleeding, respiratory troubles, trauma, and other serious problems come.

"It's so busy that we can't bring in more patients," she says. As all beds are taken, the E.D. is currently on "divert," meaning ambulances are being diverted to other hospitals. "People can still come in on foot, of course."

We dip into other rooms—surgery, orthopedics, radiology. I'm having a hard time getting my bearings in this honeycomb-like space. It's as busy as a hive, with assorted people darting about—physicians, residents, nurses, technicians, patients, family members, EMTs, police. It's surprising how calm and relaxed everyone seems despite this buzz of activity.

"Want some?" a resident carrying a steaming pizza box asks Finkel as we dash down another hallway.

"Love some," Finkel responds but keeps moving.

"It's slow, but if it picks up, it could get horrific—crazy kid stuff."

6:58 p.m.

Back in Acute/Trauma, EMTs push through the swinging doors with a middle-aged woman strapped to a gurney. Two policemen follow them into Bay 1. She's from a nearby prison and now and then launches into a raving tirade.

7:08 p.m.

My first patient turns me down. That is, the woman behind the drawn-across curtain of Bay 5 says no when Gustin, my liaison officer, asks if she would mind having a reporter listen in while Finkel examines her; he will not use names, she says, and will leave upon request. No.

I can't blame her. If I were in the same position, I'd probably say no, too.

7:10 p.m.

Even as I think, "With all these people running around, how does anybody know who anybody else is?" I notice that everybody is discreetly staring at me. The looks are not threatening, just curious. I must stand out like a sore thumb.

7:15 p.m.

Gustin waves me into Bay 7, where a 36-year-old man passed out at work today without any warning.

7:20 p.m.

Outside the bay, Finkel confers with Dr. Jonathan Fisher, the chief resident, then turns to me. "It's strange. With old people, we think arrythmia." Arrythmia is a change in heartbeat rhythm. "But he's so young." Why would a guy so young suddenly pass out?

Residents mill about, take calls, work at computers, joke amongst themselves. Chairs with coats thrown haphazardly over them belong to anyone who wants to sit there—no sense of private possession here. Strong sense, however, of hugely talented people forced to wait around, hungry to be of service. But we remain on divert.

HOUR TWO
7:39 p.m.

One of those strange moments that sometimes happens in noisy places when all becomes suddenly much quieter, as if somebody turned down the volume. Fewer people around, hallways near-empty.

7:50 p.m.

Finkel and several residents gather around a wall-mounted board to discuss patients, most of whom Finkel has yet to see. The board lists each patient's last name, along with his or her complaint, room number, time in, registered nurse, and any labwork, X-rays, or other tests.

The doctors speak fast and, to my untrained ears, in a kind of code punctuated with medical terms, drug names, unfamiliar treatments. As they make their way quickly down the board, I scribble down a welter of phrases that later prove utterly meaningless out of context: his chest X-ray is pending ... right upper extremity numbness ... urine is clean ... no neurologic symptoms....

One comment of Finkel's stands out, however: "I don't know what's wrong with him yet, so that's a problem." It sums up the doctors' unanimous stance: Concern for patients, thrill at a challenge, certainty of eventually pinpointing the problem.

"Listen, I'm an old man, I'm ready to die," he says, sighing.

8:01 p.m.

"You guys have the best job!" says an RN sarcastically to one of the policemen guarding the incarcerated woman, who has begun raving again.

"Why do I always get the nut cases?" asks one, a beefy, good-natured cop. He jerks his thumb back towards Bay 6, to which the woman's been moved. "She's not playing with a full deck."

8:09 p.m.

As Finkel excuses herself to attend to a patient outside Acute/Trauma, I watch as a group of first- and second-year medical students gets the same treatment I do: A resident asks a patient if he'd mind a group of students listening in. He doesn't, and they slip behind the curtain.

"They get to see a wide variety of patients and integrate what they learn here with what they learn in the classroom," Dr. Dana Stearns, an attending physician, tells me. Stearns runs this course, which is so popular that he had to choose the 45 students currently enrolled by lottery.

Noticing me as we chat stepping this way and that to avoid hustling residents, gurney-pushing EMTs, and technicians with portable X-ray machines, Stearns smiles and says "we call it organized chaos."

"It doesn't seem chaotic right now," I say.

"Just wait. It'll change like New England weather."

A nurse standing nearby uses that to comment about young hot-rodders taking their wheels out in this storm. "It's slow, but if it picks up, it could get horrific—crazy kid stuff."

8:15 p.m.

Finkel tells me how busy it normally is. On a recent night, she says, she charted a patient on average every 11 minutes. "It's paradoxical. It's so busy that it's not. I mean, I'm sitting here talking to you. It's unbelievable. You'll see tonight when Tancredi takes over, when you're by yourself on the overnight shift, you're practically running." Dr. David Tancredi will take over for Finkel as the attending physician at 11 p.m., but at 1 a.m., he takes over for all five attendings currently here.

HOUR THREE
8:33 p.m.

Since things are slow, Gustin and I head to a coffee shop down the hall for a break. It will be the only one I'll get all night. As I order a bagel and coffee, I wonder if Finkel ever got any of that pizza.

8:54 p.m.

Back in the E.D., I listen in as Finkel, the chief resident Fisher, and a nurse discuss the incarcerated woman, whom Finkel has just seen. The woman has begun hallucinating.

"She told me to stop drooling on her," Finkel says, chuckling. "I said, 'I don't think I'm drooling.' And she said, 'Well, at least stop spitting at me. And watch out for the dog.'" The woman claimed that a half-lab, half-terrier was walking around in the room.

The joking, de rigueur in hospitals everywhere, keeps things from getting tense. But Finkel soon returns to trying to diagnose her ailment.

"Right," Finkel responds, in a matter-of-fact tone that suggests she's already thought of that, way back.

8:58 p.m.

We pause by Bay 2, where an elderly man lies drifting in and out of sleep. He took too much heart medication, and his heart rate has slowed into the 30s. "He feels fine," Finkel says, raising her eyelids in mild amazement and smiling. So to make room for other patients, he will soon be moved to the so-called Step-Down Unit.

9:05 p.m.

A nurse tells Finkel there's an old man in the hallway who has reduced his own hernia, because he was sick of waiting. A hernia occurs when an organ such as the intestine pokes through muscle layers; some patients can reduce their own hernias—that is, push them back where they belong.

"He says he's been his own doctor for years," the nurse says.

"Okay, he can go, but let me see him first," Finkel says. No one can leave the E.D. without first being seen by a physician.

Out in the hallway Finkel approaches a bearded gentleman in a black suit and white buttondown shirt, half-sitting, half-leaning on an unused gurney. Standing a discreet distance away, I can see numerous people in the waiting room.

"I was in great pain," the man tells her, hands clasped before him. "I found no relief here, so I applied my own expertise."

"First let me say I'm terribly sorry this happened," she says, referring to his having to wait. "The entire place is full. That's not an excuse, it's a reason." She crosses her arms. "We're between a rock and a hard place. We can't give medication in the hallway."

There's nothing more to be done. As Finkel disappears into Acute/Trauma, promising to notify the man's doctor, I hear him say to no one in particular, "I've never felt this weak before."

Finkel devours a banana. It's the first thing I've seen her eat.

9:24 p.m.

"I'm not happy about him leaving, but he seems competent," Finkel tells me. "I really try to stay off divert. People need to be seen here. This guy probably was in a lot of pain. It's not good when so many people are waiting."

She pauses, smiling humorlessly. "People are screaming, 'I've been waiting three hours.' Three hours? I think. That's not so bad." Unfortunately, a typical wait is four to six hours, because of the lack of beds and because doctors have to see the most seriously ill patients first.

The doctors and everyone else who works in the E.D. are certainly not sitting around. "Many times I'll be here for hours, literally running between patients," Finkel tells me. "I haven't eaten, haven't gone to the bathroom." She shakes her head and bends to fill out the hernia man's chart.

It's the first time I've heard her talk about her own good, not just that of her patients. Overcrowding and short-staffing—nationwide problems that clearly affect both sides.

HOUR FOUR
9:37 p.m.

Finkel visits a man in Bay 5. He has a brain tumor and was evaluated at Mass General about a month ago for possible surgery. But he was brought in today for coughing symptoms that might indicate pneumonia.

During her questioning, Finkel learns that the man has had trouble speaking for a day. He gets a word out, but then stops as if frozen. As Finkel patiently extracts information from him word by word, another doctor sweeps into the room. He's seen the patient before and gives him a hail-fellow-well-met pat on the shoulder.

"Is anyone here with you?" No. "Does anyone know you're here?" Yes. "Okay, we're going to touch base with them to try to find out exactly how long the problem's been going on, all right? Do you—"

"Okay, now it's coming back, it's all coming back," the newly arrived doctor interrupts, turning to a gaggle of med students that came in with him. He points to a series of brain scans on the viewbox, in which the tumor is clearly visible. "He has a mass that was biopsied in an outside hospital about two months ago. It's a glyoma. Unfortunately, it's in his speech area."

The man agreed to allow me in (as well as Gustin and the medical students), but I feel badly for him that his very serious condition is made so openly public before a crowd of strangers. At the same time, while I prefer Finkel's gentler bedside manner, I realize the other doctor is not unkind and is simply doing his job, which includes teaching the next generation.

9:47 p.m.

While she talks with a resident about a patient in for disimpaction of his bowel, Finkel devours a banana. It's the first thing I've seen her eat.

9:54 p.m.

The 36-year-old man who passed out at his office signs his own release and leaves.

9:57 p.m.

In Bay 6, Finkel drops in on a courtly Italian gentleman of 61 who's had a constant pain in his chest since this afternoon. Finkel begins asking her litany of questions, which the man's bearded son, still in his overcoat, translates for him.

When she asks about smoking, the father answers himself: "I stopped two years ago."

"Good for you. That's wonderful." Her passion.

After examining the man, during which she discovers that she and the patient and Gustin all have the same birthday, Finkel gives her usual thorough summing up.

"Okay, this is the story. I'm not sure what's causing this discomfort. It could be just muscle pain. The problem is, it's very hard to tell if someone is having heart pain or not, especially someone your age. We worry a lot more. Some of what you've told me sounds like heart, and some doesn't."

She goes on without pause.

"We'll get a chest X-ray. Your EKG is funny-looking, but it's always been funny-looking, so that's reassuring actually. But I think we need to take what you're saying pretty seriously, because you do have some risk factors for heart disease. I'm not saying you've had a heart attack. But I do wonder if maybe your heart is trying to tell you that it's not getting enough oxygen. It could be just muscle, but in the emergency room we are just very careful."

"Especially because you have the same birthday!" says the son brightly. "You really have to take care of him."

"Yes, all three of us are bonded," Finkel says and then we leave, smiles all around.

"Oh, I thought you were going to tell me I was dying. Sure, bring him in."

10:17 p.m.

Dr. Bret Nelson, a resident who has made some calls, tells Finkel that the incarcerated woman has no history of schizophrenia, and that the phone numbers the woman's been giving for people to contact are no good.

"She said I drooled, too, and clearly that's true," Fisher responds with a smirk.

"Fish," a stout, amiable 29-year-old who reminds me both in looks and lively personality of the actor Richard Dreyfuss, has an irreverent sense of humor that the other staff members clearly savor. At age four, in the hospital for a throat infection, Fish had an emergency cricothyrotomy in an elevator—doctors placed a breathing tube in his dangerously constricted throat. That saved his life, but between then and age 10, he had 40 surgeries.

Fish was left with no voice, so he whispers like someone with laryngitis, even across the E.D. He was also left with an abiding interest in helping the sick and injured. He first became an EMT, then got a masters in public health, and finally graduated from Tufts Medical School and came here.

10:26 p.m.

Finkel asks a 94-year-old woman with a swelling on her calf whether I can come in. I hear a tiny, charming voice behind the curtain: "As old as I am, I'm still very bashful."

Finkel assures the woman that when she examines her, she'll ask me to leave. The woman gives her assent, and Finkel gets on with her questioning.

"You a smoker?" Finkel asks.

"Never in my life."

"Good for you."

The swelling looks worrisome, and Finkel, concerned about a possible blood clot, orders an ultrasound.

HOUR FIVE
10:37 p.m.

A cancer patient in her 60s initially misunderstands when Finkel asks her if I can come in. Upon clarification, the woman says, "Oh, I thought you were going to tell me I was dying. Sure, bring him in."

After examining the woman, who recently had an esophagectomy (an operation on her esophagus to remove cancer), Finkel deems her pain a surgical complication and calls for a surgeon to come see her.

10:53 p.m.

A newly arriving resident says that the storm has dumped seven inches of snow so far.

10:58 p.m.

A new pair of cops arrives to relieve the two who have guarded the incarcerated woman for four hours. Moments later, Dr. David Tancredi appears, ready to take over for Finkel.

Tancredi's pedigree is impressive: Harvard undergrad, followed by graduate studies in philosophy and Harvard Medical School. He's now finishing up a Ph.D. in anthropology, which took him to Mexico for a year to research how to bring modern medicine to rural Indians.

Slight of build, eyes alive with intelligence, Tancredi exudes an aura remarkably avuncular for someone not yet 40. As we gather by the patient board so Finkel can fill Tancredi in, residents crowd around him like students before a respected teacher, seeking his approval of their diagnoses.

After hearing about all the patients, Tancredi decides not to renew the divert. Mass General is again open to ambulances.

11:20 p.m.

Having finally unloaded everything she knows about the 10 patients in Acute/Trauma, Finkel leaves for the night.

HOUR SIX
11:32 p.m.

Standing by the patient board, Tancredi and Fish trade possible diagnoses for the incarcerated woman. A heavy drinker, she had her last drink four days ago, when she was taken to jail. So withdrawal seems likely, yet aspects of her vital signs give them pause.

When Fish launches into the light banter, Tancredi doesn't miss a beat.

Fish: "Why can't she be just plain old nuts?"

Tancredi: "Could be withdrawal."

Fish: "Just give her a beer."

Tancredi (looking at me): "We used to stock it. Really." In the past, he adds, before the advent of other medications for alcohol withdrawal.

Fish: "Best antidote to d.t.'s."

Tancredi (still looking at me): "It was cheap beer, though."

A resident continues trying to sedate her so he can perform tests that might confirm the diagnosis of withdrawal.

"It's nearing last call. I'd like to keep a bed open for a crash victim."

11:39 p.m.

In Bay 1, I see my first patient with Tancredi. She's a red-haired woman in her 50s or 60s who has pain in her legs, which have had blood clots in the past. Tancredi bends over and leans on the bed's railing, only a foot or two from the patient's face. It's a personal touch that he'll bring to every patient encounter tonight. He tells her he will order an ultrasound of her leg to see if the pain is being caused by a clot or is musculoskeletal in nature.

11:48 p.m.

With beds unavailable in Pediatrics, a premature baby whom I can see waving its arms and legs vigorously on a bed in Bay 2 is moved to Bay 17 in MAMP.

11:56 p.m.

Tancredi heads out to the reception area to check on a man in a wheelchair, who has a heart condition and is having trouble breathing. I have to double my normal walking speed to keep up. Tancredi's preferred stride is a near-run, as if everything's a crisis, which I guess is not an inappropriate way for an E.R. doctor to think. Even when he's not moving, Tancredi's natural forward lean gives one the impression that he's about to start forward at any moment and one should be prepared to get out of the way.

11:58 p.m.

After a brief discussion with the wheelchair man, Tancredi turns to talk to a mother who is holding a bloody cloth to the head of her 15-year-old son, a hemophiliac who got drunk and fell down some steps. Her ringed fingers are stained with blood.

"Do you know how bad his hemophilia is?"

"It's 10 percent."

"Okay. Have we seen him here?"

"Yes. We always come here. We see Dr.—."

"Great. That means we'll have all the records. Okay, we're going to put a collar on him, and we'll see you in a few minutes."

As Tancredi turns to leave, a male nurse takes hold of the semi-alert boy's shoulders and says, "I'm going to have to lay you down, buddy, and put a hard collar on your neck...."

12:00 a.m.

As Tancredi passes the old man with low heart rate in Bay 2, who still hasn't been moved to the Step-Down Unit, he pauses. He takes in data flashing on the patient's monitor, which still shows a heart rate in the 30s, then shuffles over to his bedside. He looks quizzically between the dozing patient and his monitor, and says half to himself but with a tone of urgency, "Is this guy all right?"

A nurse ambles slowly into Bay 2, her seeming somnambulance a stark counterpoint to Tancredi's hyperkinesis. "He's been like that for hours," she says languorously. She couldn't sound less urgent.

What she means is that she's been watching him closely for hours, his mental status and blood pressure are normal, and he's not in distress. Having got what he needs, Tancredi shrugs, smiles at me, and moves off.

12:06 a.m.

EMTs burst through the double doors, wheeling in a gurney bearing an unconscious man dressed only in boxer shorts. Though he's out cold, the man appears young and fit. Ten people crowd into Bay 3: four EMTs, two cops, Tancredi, Fish, Dr. Heikki Nikkanen (a resident), and an RN.

Even as Fish begins to joke around, he straps an oxygen mask on the patient and, along with Nikkanen and the nurse, begins attaching various diagnostic devices and tubes to the man's chest and arms. Tancredi watches the monitor, questions the EMTs who brought him in, and orders a portable chest X-ray unit to Bay 3. I stay out of everybody's way.

12:18 a.m.

Tancredi steps out of Bay 3 for a moment, and, not knowing what is going on, I risk asking him to give me an update. He seems only too happy to do so.

"It's probably DKA—diabetic ketoacidosis. He has a history of diabetes, and he's had relative insulin deprivation, meaning that his blood sugar's way up. Even though he's got all this sugar in his blood, his body's perceiving that he doesn't have enough. Ketoacids have built up, and he's entered ketoacidosis."

Tancredi glances back at the monitor. Just as he does so, the semi-conscious patient rises halfway up off the bed for a moment, and Fish gently pushes him back down. When he sees the patient is calm, Tancredi turns back to me.

"He's got a change in his mental status and a change in his EKG, which means he could have a really high level of potassium. He could have had a heart attack. All these things are still tests away. We don't know. You kind of take your best shot."

That is, when confronted with a condition as serious as this, an E.D. doctor often has no choice but to act before all the data are in.

12:22 a.m.

Everybody clears out of Bay 3 for the chest X-ray. Tancredi is the first back in.

12:26 a.m.

The patient, still unconscious, lies alone in Bay 3. Everything that can be done for him for the moment has been done.

A woman at the main desk gets on the intercom: "Transport to Trauma. Patient going to the unit. Transport to Trauma. Patient going to the Step-Down Unit."

HOUR SEVEN
12:30 a.m.

The elderly man with the low heart rate is finally wheeled out of Bay 2. Glancing at the clock, Fish nods toward the empty bay and says matter-of-factly to Tancredi, "It's nearing last call. I'd like to keep a bed open for a crash victim."

Tancredi nods and continues scribbling notes on the unconscious man's chart. I ask Fish about the cause of the man's diabetic reaction.

"It could be an infection, or maybe the guy's not complying with his medication." He pauses and looks up at me. I expect a joke, but I don't get it. "This is what kills young diabetics," he says and takes another look at the monitor in Bay 3.

12:35 a.m.

Tancredi visits the wheelchair man, now ensconced in Bay 4. When the patient tells him he previously had a heart attack and bypass surgery for his legs, Tancredi asks what medicines he's currently taking.

"Right now, none."

"Really? Does your cardiologist know?"

"Well, I haven't seen him for a year."

"Ah, three years," his wife pipes in.

After a few more questions and an examination, Tancredi tells him he should be taking his medication, and he offers his diagnosis.

"Here's the story. Signs are that you have early congestive heart failure. What we're in the business of doing down here is ruling out the biggest threats, the worst things that it could be. To me, that's the thing I would be most worried about."

"So what I'd do is bring you into the hospital, get an ultrasound of your heart. We'll be able to tell from that how well your heart is pumping. Then we'll have an idea of what kinds of medications you can get and where we're thinking you are on that curve of congestive heart failure."

"He's not going to like this. Both his hands are tied, right?"

1:07 a.m.

"Weather always stops it," a resident says by way of explaining the lack of trauma victims tonight and the generally more subdued atmosphere.

1:18 a.m.

"He's obviously pretty healthy, because he's making it through this fairly well," Tancredi responds.

"Well, to be honest with you," says the father, "the best thing for him would be to spend a couple of days here."

"Oh, he's definitely going to be admitted," Tancredi says. "The question is whether to put him in the intensive-care unit or not. His condition is pretty severe, and it takes a long time to get this way and a long time to get back. Also, we have to find out what the cause is, and that's hard."

1:26 a.m.

As Tancredi leans against a counter in MAMP, hospital security wheel in a drunk strapped to a gurney. Scrawny and unshaven, he curses in a loud voice till he sees Tancredi, then breaks into a broad grin and says something incomprehensible. Tancredi does a finger wave and says an extended "Hiiii." Clearly he's seen him before.

HOUR EIGHT
1:45 a.m.

As Tancredi prepares to see the hemophiliac kid in MAMP, Heikki Nikkanen stops him to say the unconscious man in Acute/Trauma is starting to come around.

1:47 a.m.

The 15-year-old hemophiliac has passed out on his bed. His parents hover over him, giving Tancredi the details of his accident. Apparently the mother found him around 11 p.m., passed out inside her house. She woke him up, and he told her he had fallen down four or five stairs outside.

Tancredi lifts the boy into a sitting position and tries to wake him up. "Who's that?" he says, pointing to the mother, who leans in close to her son. The boy looks at his mother and mumbles. Again Tancredi says "Who's that?," this time turning the boy's head towards his father. Eyes barely open, the youth mumbles once more. Tancredi lays him back on the bed, and he's immediately out.

Tancredi orders a chest X-ray. He also calls for a CAT scan of the boy's head; his hemophilia puts him at risk for bleeding into the brain.

Outside the bay, Tancredi tells me the boy's alcohol level is almost three times the legal limit.

1:58 a.m.

Tancredi visits the 94-year-old woman with the swelling on her calf. A middle-aged couple has joined her—her kids? Tancredi tells her he has ordered pain medication and that it should be there soon. He expects to release her before long.

2:00 a.m.

I sit down on a chair in MAMP and am surprised at how wonderful it feels. Then I realize it's the first time I've sat down since I arrived over seven hours ago. E.R. doctors must have that feeling all the time.

2:09 a.m.

The hemophiliac youth is awake. In fact, he walks with the help of his father to the corner of the bay to urinate in a pan. "He's looking much better now," Tancredi says—unnecessarily, I think. Then, as if reading my thoughts, he adds, "You never can tell with a hemophiliac. Since he has very little blood-clotting ability, we have to assume the worst."

2:15 a.m.

A resident suggests that a second drunk be allowed to stay overnight, what with the weather. Tancredi concurs. "I'm certainly into looking out for people who are homeless," he says. "It's one population with which we can afford to be conservative."

2:20 a.m.

"Dr. Fisher, you have a call on line—." Fish hears the page but finishes telling Tancredi about a patient before finally walking languidly to a nearby phone and taking the call, a full minute later.

The driver and any passengers have already been taken away, perhaps to the very E.D. I just left.

2:21 a.m.

Tancredi enters the bay with the drunk who recognized him earlier. The man is now passed out. Even from where I stand in the hallway outside, the smell of the man's socks is overpowering.

"We call them 'toxic socks,'" Tancredi says, unperturbed. "Sometimes you literally have to bag 'em—put bags on them." He proceeds with his examination, poking and probing, but the man doesn't react.

"He's not going to like this," Tancredi then says, holding up a red rubber tube about six inches long. "Both his hands are tied, right?" he asks an RN, who says yes.

Tancredi jams the tube up one of the man's nostrils. The man wakes violently into a sitting position and tries to blow out the tube, of which only an inch or so protrudes from his nose. Then he appears to fall asleep, still in the sitting position, head down.

Half a minute later, as Tancredi and I stand at the main desk in MAMP, I see the red tube go flying. The man has awoken, and he leaned down till his head met his shackled hand and pulled the tube out.

HOUR NINE
2:34 p.m.

In his first visit to a patient in Pediatrics, Tancredi drops in on a 10-year-old Latina girl who has abdominal pain. Half the size of an adult bay, this room's only concession to its younger occupants is a strip of wallpaper with giant alphabet letters that winds its way around the room near the ceiling.

The girl's mother is here with three other children. Since the mother doesn't speak English, Tancredi asks one of the children to translate for her—curiously, because after a question or two, he breaks into fluent Spanish himself and speaks directly to the patient.

Outside the room, Dr. Barbara Angus, a resident, catches Tancredi up on work already done on the girl. "We thought she could go home and are disinclined to do blood work, but obviously we wanted to check in with you. I don't know if you want some screening labs or...."

"The only thing I want is, she looks to me like she's a quart shy."

"Do you want her lined?"

"Well, no. Is she able to keep fluids down? She's telling me that she's been drinking a teeny bit. I'd like to make sure that she gets adequate hydration before she goes. If she can do it by mouth, I'm very happy to do it that way."

2:46 a.m.

Tancredi examines an elderly woman in MAMP who, upon his asking, says it "hurts everywhere." She's had it all: appendix out, hysterectomy, repaired hernia, breast cancer, high blood pressure, a polyp in her colon.

The woman lies on her back and doesn't open her eyes even when Tancredi leans on the rail close to her face. "I'm very tired," she says and starts to cry.

When he begins to examine her, I slip out.

2:58 a.m.

A wall monitor in MAMP starts beeping loudly, and a single word flashes in red—ASYSTOLE, which means someone's heart has stopped. I look around anxiously; no one has moved. Noticing my reaction, Fish juts his chin toward the bay in question, smiles, and says, "I can hear him talking, so clearly his heart hasn't stopped." Fish and the others seem to know instinctively when a cry means wolf and when it means a faulty monitor.

3:03 a.m.

Things have quieted down, and I've seen most of the patients who will allow me in. So I thank Tancredi and Fish for their time and turn to go. Remembering one last question, I turn back. But the doctors are already on to something else, answering a nurse who's asking if they ordered an ultrasound for a certain patient. I spin on my heels and head out.

3:40 a.m.

As I drive up Route 2 towards home, the blizzard still in full swing, I pass the scene of a one-car accident. Its roof crumpled, windshield smashed, a sports car took a nasty roll on the slick highway. A lone police car, lights flashing, remains in attendance; the driver and any passengers have already been taken away, perhaps back the way I came, to the very E.D. I just left.

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